198320031-10-6-2021-11-AS-PBUR-C7JM6C-20211006091942

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320031
Report Date: 10/04/2021
Date Signed: 10/06/2021 09:19:57 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SOUTH BAY MEMORY CARE		FACILITY NUMBER:	198320031
ADMINISTRATOR:	SPIGLANIN, LAUREN		FACILITY TYPE:	740
ADDRESS:	19318 FLAVIAN AVE		TELEPHONE:	(310) 383-1877
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY:	6	CENSUS: 6	DATE:	10/04/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Mary Lou Giebel		TIME COMPLETED:	03:30 PM

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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Required - 1 Year Annual visit. The primary focus is on the Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Bunker called the facility and spoke to Licensee Lauren Mahakian via telephone to conduct a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection.

LPA Bunker met with Director of Care Mary Lou Giebelb and explained the purpose of today's visit. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA observed a sanitizing station at the facility garage entrance; visitors log with COVID-19 screening and temperature log, and records of daily COVID-19 screening and temperature checks of residents and staff. PPE supplies are readily available to staff, and an additional over 90-day supply of PPE is stored in the storage closet; sufficient paper, cleaning, and disinfecting supplies were observed. LPA reviewed the facility’s surveillance testing records. LPA verified that the facility has an approved Mitigation Plan Report. Mrs. Giebelb stated staff and residents are fully vaccinated. All staff has completed the N95 fit testing requirement.

The facility is licensed for six (6) non-ambulatory residents, with a Dementia Care Program and an approved hospice waiver for two (2) residents. Currently, there is one (1) Hospice resident present during today’s visit.

See continued LIC809-C on page #2

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SOUTH BAY MEMORY CARE	FACILITY NUMBER: 198320031
	VISIT DATE: 10/04/2021

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Continued LIC809-C page #2

Mrs. Giebel and LPA Bunker toured the entire facility inside and outside grounds. The facility is a single-story family home located in a residential neighborhood. The facility consisted of the following: Living room, dining area, kitchen, three (3) bedrooms, three (3) bathrooms, laundry area in the garage, indoor/outdoor activity area, patio shaded area, attached two (2) car garage, front and back yard landscape is in good condition at the time of visit. Documents were posted as mandated. During the tour, LPA Bunker observed the facility’s infection control practices.

The following Title 22 regulated areas were audited and found to be in compliance: Bedrooms contain the required furniture. The resident's bedrooms were inspected for, safety, privacy, and comfort. The living areas are clean, bathrooms are clean and operational. First aid kit is fully stocked with manual, hot water temperature 119.3 degrees Fahrenheit, working telephone, smoke and carbon monoxide detectors were in compliance, fire extinguishers are fully charged, records medications is centrally stored and properly locked in the kitchen, with current record, ample supply of perishable and nonperishable food, adequate linen supply, fire/emergency drill conducted on 07/09/2021. No firearms on the premises, resident's bedroom windows have no sliding window locks with thumbscrews, all exit doors were in compliance, covered trash cans, and no bodies of water present. Hazardous items are inaccessible to clients, the yard is free of debris and hazards.

Director of Care Mary Lou Giebel states staff was given training on dependent adult and elder abuse reporting.

There were no deficiencies cited.

Exit interview conducted.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021

LIC809 (FAS) - (06/04)

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